Based on observation, interview, clinical record review, and document review, the facility failed to ensure a regular inspection of a resident's bed frame and bed rails was completed for a resident with upper bed rails attached to the resident's bed frame for 1 of 19 sampled residents (Resident #21). This deficient practice had the potential to result in a resident injury from entrapment resulting from incompatible or malfunctioning bed rails.Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, severe, with other behavioral disturbance, muscle weakness (generalized), and anxiety disorder due to known physiological condition. …
F909 citations in Nevada
Environmental Deficiencies
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Nevada cites F909 more often than its own record predicts
1.50 times the share F909 takes of citations nationally.
Of every deficiency written in Nevada in 2025, this is the portion that was F909.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Nevada surveyors wrote
F909 findings written in Nevada, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
What else Nevada surveyors cite →
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